Task Force on ‘Clinical Algorithms for Fracture Risk’ commissioned by the American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee has recommended that FRAX® models in the US do not include adjustment for race and ethnicity. This position paper finds that an agnostic model would unfairly discriminate against the Black, Asian and Hispanic communities and recommends the retention of ethnic and race-specific FRAX models for the US, preferably with updated data on fracture and death hazards. In contrast, the use of intervention thresholds based on a fixed bone mineral density unfairly discriminates against the Black, Asian and Hispanic communities in the US. This position of the Working Group on Epidemiology and Quality of Life of the International Osteoporosis Foundation (IOF) is endorsed both by the IOF and the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO).

Guidelines to provide an update of the previously published Polish recommendations for the management of women and men with osteoporosis have been developed in line with advances in medical knowledge, evidence-based data, and new concepts in diagnostic and therapeutic strategies. A Working Group of experts from the Multidisciplinary Osteoporosis Forum and from the National Institute of Geriatrics, Rheumatology, and Rehabilitation in Warsaw performed a thorough comprehensive review of current relevant publications in the field (including all age groups of people and management of secondary osteoporosis), and they evaluated epidemiological data on osteoporosis in Poland and the existing standards of care and costs. A voting panel of all co-authors assessed and discussed the quality of evidence to formulate 29 specific recommendations and voted independently the strength of each recommendation. This updated practice guidance highlights a new algorithm of the diagnostic and therapeutic procedures for individuals at high and very high fracture risk and presents a spectrum of general management and the use of medication including anabolic therapy. Furthermore, the paper discusses the strategy of primary and secondary fracture prevention, detection of fragility fractures in the population, and points to vital elements for improving management of osteoporosis in Poland.

Basing on European, American and Polish recommendation reviewed are strategy of treatment of osteoporosis. In Poland, rules of reimbursement reinforced general use of antiresorbtive drugs (bisphosponates, demosumab) in the treatment of osteoporosis. For effective therapy the key points are keeping the patient in the treatment and treatment monitoring with potential use of densitometry and bone markers.

In the rapidly ageing society in Poland, osteoporosis is a growing epidemiological problem, and osteoporosis-related fractures are a cause of chronic disability and considerable increase of death risk. It turns out that 80 to 90% of patients suffering from osteoporosis, including osteoporosis accompanied by fractures, do not receive adequate pharmacotherapy. In this paper, a Guideline Working Group of experts from the Multidisciplinary Osteoporosis Forum update the existing Polish guidelines concerning the diagnosis and management of osteoporosis (last revised in 2013), taking account of the latest literature, availability and reimbursement of drugs, and current health care organisation. In the revised guidelines, we still postulate that tasks are divided between primary care doctors (stage I) and specialists in osteoporosis management (stage II). We emphasise the necessity of early initiation of pharmacotherapy and rehabilitation in all patients with low-energy fractures. We recommend that the 10-year fracture risk should be estimated in all patients (including those without fractures) who are over 50 years of age, and that the Polish threshold for therapeutic intervention should be adopted: ≥ 10% for FRAX PL calculator. We add strategies of drug choice and therapy monitoring with imaging, and densitometric and biochemical diagnostics. We define basic guidelines concerning prevention of falls, rehabilitation, and dietary procedures, and elimination of environmental and other fracture risk factors. We point to two vital elements for improving osteoporosis management: 1) strategy of supervision over fractures management - Fracture Liaison Service (FLS), and, optimally, 2) strategies of short-term monitoring of the therapeutic efficacy with the use of biochemical markers.

W szybko starzejącym sie polskim spoleczenstwie osteoporoza stanowi narastający problem epidemiologiczny, a związane z nią zlamania są powodem przewleklej niepelnosprawności, powiklan, obnizenia jakości zycia, znacznego wzrostu ryzyka zgonow. Okazuje sie, ze 80–90% chorych cierpiących na osteoporoze, w tym osteoporoze ze zlamaniami, nie otrzymuje adekwatnej farmakoterapii. Zespol ekspertow Wielodyscyplinarnego Forum Osteoporozy aktualizuje w obecnym opracowaniu dotychczasowe polskie zalecenia diagnostyczno-terapeutyczne w zakresie osteoporozy (ostatnie ukazaly sie w 2013 r.), uwzgledniając najnowsze piśmiennictwo, dostepnośc lekow i ich refundacje oraz aktualną organizacje lecznictwa. W opracowanych zaleceniach podtrzymano postulat podzialu zadan dla lekarzy opieki podstawowej (etap I) oraz specjalistow zajmujących sie leczeniem osteoporozy (etap II). Podkreślono koniecznośc szybkiego wdrazania farmakoterapii i rehabilitacji u wszystkich osob ze zlamaniami niskoenergetycznymi, zaakcentowano potrzebe określania 10-letniego ryzyka zlaman u wszystkich osob (w tym osob bez zlaman) po 50. roku zycia z przyjeciem polskiego progu interwencji terapeutycznej (≥ 10% dla kalkulatora FRAX), uzupelniono strategie doboru lekow i monitorowania leczenia o diagnostyke obrazową, densytometryczną i biochemiczną. Podano podstawowe wytyczne dotyczące prewencji upadkow, postepowania rehabilitacyjnego, dietetycznego oraz eliminacji środowiskowych i innych czynnikow ryzyka zlaman. W aktualnych zaleceniach zwrocono uwage na dwa istotne elementy usprawnienia leczenia osteoporozy: 1 — strategie nadzoru nad leczeniem zlaman Fracture Liaison Service (FLS) oraz, optymalnie, 2 — strategie krotkoterminowego monitorowania efektywności leczenia za pomocą markerow biochemicznych.

INTRODUCTION The objective of the study was to assess dietary calcium intake in the Polish population and its influence on selected parameters of bone tissue. MATERIALS AND METHOD 1,129 osteoporosis treatment-naive subjects, aged 20-80 years, randomly selected, were involved in the study. Bone status was established using densitometry of spine and hip and quantitative ultrasound of the calcaneus. Dietary calcium intake was calculated according to data gathered in a questionnaire. RESULTS Median calcium intake was 746 mg; 72% of subjects had calcium intake below the recommended dose. Calcium intake correlated negatively with age (r = -0.15; p<0.001) and positively with BMD in the spine (r = 0.06; p<0.05) and in the femoral neck (r = 0.07; p < 0.05). In subjects with the lowest calcium intake, a significantly lower femoral neck BMD and heel stiffness was noticed than in subjects with the highest calcium intake. However, multiple regression analysis showed that dietary calcium was not a predictor of low BMD, both in the hip and spine, as well as of bone stiffness in contrast to age, low BMI and female gender (p<0.0001). In all factors regression analysis, a weak influence of calcium intake on BMD was shown only in the subgroup of premenopausal women (β = 0.1; p<0.05). CONCLUSIONS In most subjects, dietary calcium intake was below the recommended dose; however, its influence on bone seems to be weak, except for persons with the greatest deficiency of dietary calcium and the subgroup of premenopausal women.

Abstract Objective Dietary Ca is now being recognized to play an important role not only in skeletal integrity, but also in the regulation of energy and metabolism. The aim of the present study was to estimate the relationship of dairy Ca intake with BMI and blood pressure (BP) in a sample derived from the Polish population. Design Ca intake was calculated from an interviewer-administered semi-quantitative FFQ. BMI was calculated from measured weight and height, and BP was measured by a physician. Setting Cross-sectional epidemiological study on osteoporosis risk factors in Poland. Subjects Randomly selected healthy adult persons (n 1259; 750 women and 509 men). Results Dairy Ca intake was significantly lower in individuals with overweight/obesity (BMI≥25·00 kg/m2) and/or with elevated BP (systolic/diastolic ≥140/≥90 mmHg) than in those with normal body mass and BP, respectively. Ca intake was negatively correlated with BMI (r=−0·12, P<0·001), systolic BP (r=−0·11, P<0·001) and diastolic BP (r=−0·08, P<0·01). Daily dairy Ca intake below 1000 mg was a predictor for BMI≥25·0 kg/m2 (OR=1·44, P<0·005). This relationship was stronger in women, particularly premenopausal women. Conclusions The obtained results indicate the role of low dairy Ca intake in the development of obesity and hypertension, notably in premenopausal women.

OBJECTIVE The aim of this study was to examine the level of compliance and persistence in patients with postmenopausal osteoporosis (OP) receiving daily risedronate (5 mg) with either fixed dosing of three different timing regimens (A: before breakfast; B: in-between meals; C: before bedtime) or with flexible dosing and the effect on urinary N-terminal telopeptide of Type 1 collagen (NTX-1). METHODS The study included 448 patients with postmenopausal OP. Patients were randomly assigned into six treatment groups each with a permutation of the treatment sequence (ABC, BCA, etc.) in the crossover phase (3 x 1 week) and randomized to 23 weeks of either the daily flexible (either regimen A, B or C) or fixed timing (only regimen A, B, or C) in the patient's preference phase. Urinary NTX-1 was tested. RESULTS A total of 433 patients participated in the patient's preference phase (49.7% preferred flexible and 50.3% fixed timing). There was no significant difference between the proportion of responders who were both compliant and persistent in the flexible (54.4%) and fixed regimens (53.7%) (p=0.8803). A significant difference between the flexible and fixed regimens was seen in persistence in favor of the flexible regimen (p=0.0306). There was no significant difference between the flexible and fixed regimens in terms of compliance (p=0.4611). Change in urinary NTX-1 did not show any difference between the two regimens. At the final visit, 51% of patients in the flexible and 55% in the fixed regimen group considered the used risedronate regimen as excellent or very good (p=0.1440). CONCLUSION A flexible dosing with daily risedronate appears be a valuable option in terms of compliance and persistence for patients with postmenopausal OP.

Quantitative ultrasound of the heel captures heel bone properties that independently predict fracture risk and, with bone mineral density (BMD) assessed by X-ray (DXA), may be convenient alternatives for evaluating osteoporosis and fracture risk. We performed a meta-analysis of genome-wide association (GWA) studies to assess the genetic determinants of heel broadband ultrasound attenuation (BUA; n = 14 260), velocity of sound (VOS; n = 15 514) and BMD (n = 4566) in 13 discovery cohorts. Independent replication involved seven cohorts with GWA data (in silico n = 11 452) and new genotyping in 15 cohorts (de novo n = 24 902). In combined random effects, meta-analysis of the discovery and replication cohorts, nine single nucleotide polymorphisms (SNPs) had genome-wide significant (P < 5 × 10(-8)) associations with heel bone properties. Alongside SNPs within or near previously identified osteoporosis susceptibility genes including ESR1 (6q25.1: rs4869739, rs3020331, rs2982552), SPTBN1 (2p16.2: rs11898505), RSPO3 (6q22.33: rs7741021), WNT16 (7q31.31: rs2908007), DKK1 (10q21.1: rs7902708) and GPATCH1 (19q13.11: rs10416265), we identified a new locus on chromosome 11q14.2 (rs597319 close to TMEM135, a gene recently linked to osteoblastogenesis and longevity) significantly associated with both BUA and VOS (P < 8.23 × 10(-14)). In meta-analyses involving 25 cohorts with up to 14 985 fracture cases, six of 10 SNPs associated with heel bone properties at P < 5 × 10(-6) also had the expected direction of association with any fracture (P < 0.05), including three SNPs with P < 0.005: 6q22.33 (rs7741021), 7q31.31 (rs2908007) and 10q21.1 (rs7902708). In conclusion, this GWA study reveals the effect of several genes common to central DXA-derived BMD and heel ultrasound/DXA measures and points to a new genetic locus with potential implications for better understanding of osteoporosis pathophysiology.

Background Osteoporosis is a systemic skeletal disease characterised by reduced bone mineral density and increased susceptibility to fracture; these traits are highly heritable. Both common and rare copy number variants (CNVs) potentially affect the function of genes and may influence disease risk.Aim To identify CNVs associated with osteoporotic bone fracture risk.Method We performed a genome-wide CNV association study in 5178 individuals from a prospective cohort in the Netherlands, including 809 osteoporotic fracture cases, and performed in silico lookups and de novo genotyping to replicate in several independent studies.Results A rare (population prevalence 0.14%, 95% CI 0.03% to 0.24%) 210kb deletion located on chromosome 6p25.1 was associated with the risk of fracture (OR 32.58, 95% CI 3.95 to 1488.89; p=8.69x10(-5)). We performed an in silico meta-analysis in four studies with CNV microarray data and the association with fracture risk was replicated (OR 3.11, 95% CI 1.01 to 8.22; p=0.02). The prevalence of this deletion showed geographic diversity, being absent in additional samples from Australia, Canada, Poland, Iceland, Denmark, and Sweden, but present in the Netherlands (0.34%), Spain (0.33%), USA (0.23%), England (0.15%), Scotland (0.10%), and Ireland (0.06%), with insufficient evidence for association with fracture risk.Conclusions These results suggest that deletions in the 6p25.1 locus may predispose to higher risk of fracture in a subset of populations of European origin; larger and geographically restricted studies will be needed to confirm this regional association. This is a first step towards the evaluation of the role of rare CNVs in osteoporosis.

To decrease the risk of osteoporotic fractures in Poland, the Multidisciplinary Osteoporotic Forum has set up a joint Working Group including the representatives of the Polish Associations of Orthopedics and Traumatology, Rehabilitation, Gerontology, Rheumatology, Family Medicine, Diabetology, Laboratory Diagnostics, Andropause and Menopause, Endocrinology, Radiology, and the STENKO group as well as experts in the fields of rheumatology, obstetrics, and geriatrics to update the Polish guidelines for the diagnosis and management of osteoporosis in men and postmenopausal women in Poland. The assessment of fracture risk and intervention thresholds was made using the FRAX® calculation tool for Poland. The strength of recommendations was evaluated according to the principles of the Scottish Intercollegiate Guidelines Network and the results have been approved by national consultants. Finally, the Working Group has formulated the updated guidelines and recommended two -step diagnostic and therapeutic procedures. The first stage applies to family physicians or general practitioners and involves the assessment of fracture risk using the FRAX®-BMI to identify patients at high risk of fractures. An osteoporotic fracture remains an absolute indication both for the general practitioner and specialist to implement treatment. At the second stage, the specialist (in an osteoporosis or other specialty clinic) should review the primary or secondary causes of fracture risk, confirm the diagnosis, and introduce an appropriate treatment and monitoring. In patients (men aged >50 years and postmenopausal women) without low-energy fractures, the absolute risk of fractures exceeding 10% should be considered an indication for treatment. The Polish guidelines were compared with other international guidelines in terms of diagnostic measures, pharmacotherapy, as well as calcium and vitamin D supplementation.

INTRODUCTION Inadequate calcium intake is a recognized osteoporosis risk factor. The aim of the study was to estimate calcium intake in women in the Łódż population, the influence of calcium intake on bone mineral density (BMD) and fracture incidence, as well as the relationship between calcium intake and age. MATERIAL AND METHODS This cross-sectional investigation is a part of the EPOLOS study (a multicentre, population-based study on osteoporosis risk factors in Poland). In this study, 277 women from the Lodz urban area were involved [aged 20-80 years, not treated for osteoporosis before]. BMD was measured by dual-energy X-ray absorptiometry (DXA) in the lumbar spine and femoral neck. Fractures were self-reported and calcium intake was calculated according to data gathered in a questionnaire. RESULTS An average daily calcium intake was 797 ± 432 mg. 65.7% of the examined women took less calcium than 1,000 mg/daily. Daily calcium intake decreased with age - from 903 mg between 20-30 years of age, to 624 mg between the ages of 70-80. In women aged 50 and older, the prevalence of low BMD at the lumbar spine (T-score <-1.0) was 31.9%. Patients reported 75 low-trauma fractures. There was a weak negative correlation between age and calcium intake, and no correlation between BMD and calcium intake. Women with fractures were significantly older than women without fractures, had significantly lower BMD, and similar levels of calcium intake. CONCLUSIONS 1) Calcium intake below the recommended dietary intake was found in the majority of examined women. 2) No correlation between calcium intake and BMD, and between calcium intake and fracture incidence may suggest the involvement of factors other than calcium intake in pathogenesis of osteoporosis development. 3) Calcium intake gradually diminished with the age of the women.

Little published information is available regarding epidemiological data on vitamin D status in the large geographical region of Central Europe (CE). We searched the journal literature with regard to 25(OH)D concentrations among community-dwelling or healthy people living in CE. 25(OH)D concentrations varied by age, season, study sample size, and methodological approach [i.e., 25(OH)D assay used]. Concentrations of 25(OH)D in CE appeared lower than 30 ng/mL, and the magnitude of hypovitaminosis D was similar to that reported in Western Europe. While most of the studies reviewed were cross-sectional studies, a longitudinal study was also included to obtain information on seasonal variability. The longitudinal study reported wintertime 25(OH)D values close to 21–23 ng/mL for all studied age groups, with a significant increase of 25(OH)D in August reaching 42 ng/mL for those aged 0–9 years, but only 21 ng/mL for the elderly aged 80–89 years. The decrease in 25(OH)D with respect to age was attributed to decreased time spent in the sun and decreased vitamin D production efficiency. Based on the literature review on vitamin D status in the CE populations, it can be concluded that 25(OH)vitamin D levels are on average below the 30 ng/mL level.

INTRODUCTION:Adequate Vitamin D intake and its concentration in serum are important for bone health and calcium-phosphate metabolism as well as for optimal function of many organs and tissues. Documented trends in lifestyle, nutritional habits and physical activity appear to be associated with moderate or severe Vitamin D deficits resulting in health problems. Most epidemiological studies suggest that Vitamin D deficiency is prevalent among Central European populations. Concern about this problem led to the organising of a conference focused on overcoming Vitamin D deficiency.METHODS:After reviewing the epidemiological evidence and relevant literature, a Polish multidisciplinary group formulated theses on recommendations for Vitamin D screening and supplementation in the general population. These theses were subsequently sent to Scientific Committee members of the 'Vitamin D - minimum, maximum, optimum' conference for evaluation based on a ten-point scale.With 550 international attendees, the meeting 'Vitamin D - minimum, maximum, optimum' was held on October 19-20, 2012 in Warsaw(Poland). Most recent scientific evidence of both skeletal and non-skeletal effects of Vitamin D as well as the results of panellists' voting were reviewed and discussed during eight plenary sessions and two workshops.RESULTS:Based on many polemical discussions, including post-conference networking, the key opinion leaders established ranges of serum 25-hydroxyVitamin D concentration indicating Vitamin D deficiency [< 20 ng/mL (< 50 nmol/L)], suboptimal status [20-30 ng/mL(50-75 nmol/L)], and target concentration for optimal Vitamin D effects [30-50 ng/mL (75-125 nmol/L)]. General practical guidelines regarding supplementation and updated recommendations for prophylactic Vitamin D intakes in Central European neonates, infants, children and adolescents as well as in adults (including recommendations for pregnant and breastfeeding women and the elderly) were developed.CONCLUSIONS:Improving the Vitamin D status of children, adolescents, adults and the elderly must be included in the priorities of physicians,healthcare professionals and healthcare regulating bodies. The present paper offers elaborated consensus on supplementation guidance and population strategies for Vitamin D in Central Europe.

Searchable abstracts of presentations at key conferences on calcified tissues ISSN 2052-1219 (online)

Major aims of the 5th Central and Eastern Europe (CEE) Summit on Osteoporosis held in Bratislava, Slovakia, on 2 and 3 December 2011, were to provide participants with state-of-the-art knowledge in the fields of osteoporosis research, diagnosis, and therapy and to evaluate, compare, and discuss the very heterogeneous health care situations and related challenges in the different countries in CEE and elsewhere. The summit was attended by 70 delegates from 15 countries. State-of-the-art lectures given by international authorities on osteoporosis covered a broad spectrum of topics ranging from osteoporosis in the male population, novel therapies in osteoporosis such as cathepsin K and sclerostin inhibitors, and the implementation and use of FRAX® in CEE, to an update on denosumab for the management of osteoporosis. Workshops organized to enable the exchange of individual experiences addressed the importance and current availability of osteology training for physicians and the impact of patient training programs on therapy compliance. Furthermore, the availability of and need for standardized quality controls and therapy guidelines in different CEE countries were discussed. Finally, based on a questionnaire, a very up-to-date analysis of all participating countries regarding incidences of osteoporosis, commonly used diagnostic and therapeutic measures, the number of specialists and specialized hospitals, and differences in the reimbursement situation in the different countries was generated and presented. On the whole, the very authentic contributions and the synergistic exchange of ideas allowed the identification of both positive developments as well as still existing issues and needs in diagnosis and therapy of osteoporosis.

Searchable abstracts of presentations at key conferences on calcified tissues ISSN 2052-1219 (online)